Improving Transitions of Care:

I-PASS Handoff Initiative

Karin A. Sloan, MD

Director of Clinical Quality, Dept of Medicine

on behalf of the Core I-PASS Implementation Team for Internal Medicine:

David Yuh, hospitalist/Quality Leader inpatient GIM; Faisal Rahman, Chief

Resident; Katy Thompson, Chief Resident; Jordan Yoder, PGY3; Aravind Menon,

PGY2; Craig Noronha, APD, Epic clinical lead for handoff tool

Context

• Shorter shifts � more frequent handoffs

• Having a cross-covering physician increases risk of a

potentially preventable adverse event by 6-fold

• The CLER Transitions of Care domain calls for:

– Standardized format for handoffs

– Standardized process for handoffs (e.g. Epic handoff tool)

– Process for supervision of handoffs

Opportunities identified for improvement

during CLER needs assessment at BMC

• Education in optimal handoffs– Less than half of training programs reported that they had any formal

training in handoffs

• Quality of handoffs

• Consistency across training programs

• Supervision of handoffs

I-PASS at BMC

• Transitions of Care subcommittee formed 2014 of residents and faculty stakeholders from different programs to develop a plan for improving Transitions of Care at BMC

– Endorsed I-PASS handoff bundle

• Best evidence for reducing preventable adverse events

• Chris Landrigan, I-PASS Study PI, gave Medicine Grand Rounds Oct 2014, during Quality Week

• Obtained BMC leadership support to move towards I-PASS as handoff format for physicians and nurses across BMC

– Nursing is currently rolling out a bedside handoff initiative “I-PASS with SAFETY”

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Number of errors (rate per 100 patient admissions)

Pre(n=5516 admissions)

Post(n=5571 admissions)

P-value

Overall rate of medical errors 24.5 18.8 <0.001

Preventable adverse events 4.7 3.3 <0.001

Near misses / non harmful medical errors 19.7 14.5 <0.001

Non-preventable Adverse Events 3.0 2.6 0.48

23% reduction30% reduction

Starmer AJ et al., New Engl J Med 2014; 371:1803-12

The I-PASS Mnemonic

I Illness Severity • Stable, “watcher,” unstable

P Patient Summary • Summary statement

• Events leading up to admission

• Hospital course

• Ongoing assessment

• Plan

A Action List • To do list

• Timeline and ownership

S Situation

Awareness and

Contingency

Planning

• Know what’s going on

• Plan for what might happen

S Synthesis by

Receiver

• Receiver summarizes what was heard

• Asks questions

• Restates key action/to do items

Starmer. Pediatrics. 2012 Feb;129(2):201-4.

Participation in Society of Hospital Medicine-

IPASS Mentored Implementation Program

• With program leadership support, Internal Medicine

program applied to participate and was selected

• AHRQ-funded project with the aim of disseminating

I-PASS to 32 additional institutions

• We have been highlighted as site that has completed

all milestones thus far

• Allows access to all of the I-PASS curricular materials

• In scope for program:

MP3 and MP4

I-PASS training completed to date

• With the support of GME leadership, every incoming BMC

intern participated in simulated training in I-PASS handoffs

at orientation

– 1 facilitator: 1 to 2 groups of 3 interns, each intern practiced

giving, receiving, and observing a handoff

• Internal Medicine noon conference held in early June for

PGY2s and PGY3s and supplemental curriculum planned

for July ambulatory half day sessions

• 4 champion trainings held for Chief Residents and faculty

from many BMC departments

A big *thank you* to

champions/facilitators in Dept of Med• Served as facilitators for Intern

Orientation:

• Sheilah Bernard

• Rachel Casas

• James Hudspeth

• Nyra Khetarpal

• Rob Lowe

• Rachel Simmons

• Mike York

• David Yuh

• All Chief Residents: Nick Bosch, Katy Thompson Brunner, Faisal Rahman, Usman Tahir, Stephanie Toth, Sasha Wong

• Completed champion training:

• Patrick Fleming

• Henri Lee

• Aravind Menon

• Tom Ostrander

• Carol Sulis

• Deborah Whalen

• Jordan Yoder

Plan for MP3 and MP4 services

• We are asking those on MP3 and MP 4 to:

1. Conduct 2 observations and feedback of handoffs over the 3 week rotation and use the handoff observation forms (of giver, receiver, and written).

• Team Resident: week 1

• Attending: week 2

2. Fill out the end-of-rotation survey on the quality of handoffs.

• Faculty who participate in this initiative will be eligible for MOC Part 4.

Goals of observations and feedback of

handoffs

• Accountability for use of I-PASS and to ensure

sustainment

• Opportunity for formative feedback

• Increase supervision of handoffs

• While MP3 and MP4 are officially participating in the I-

PASS Mentored Implementation program, we will likely

be developing a similar plan for observations and

feedbacks of handoffs on other services

• At a minimum, for trainees who don’t rotate on those services

Next steps for I-PASS handoffs across BMC

• Partnering with CIR housestaff QI Council

• Forming a BMC I-PASS Committee with a representative from each training program

• Each program will be expected to:• Use I-PASS handoff format

• Use Epic handoff tool

– Work with eMERGE team to optimize

• Develop a plan for supervision of handoffs

• Submit data on observations of handoffs so we can follow adoption

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EPIC I-PASS handoff tool (currently most Medicine teams are using)

How faculty can support the I-PASS handoff initiative

• Familiarize yourself with I-PASS and support the I-PASS

format

• Emphasize the importance of transitions of care in

optimizing patient safety

• Support a protected space and time for handoffs

• Participate in this initiative by conducting live handoff

observations to be eligible for MOC Part 4 credit

• BMC now has MOC portfolio sponsor status from the American

Board of Medical Specialties and we are working towards

making this initiative institutionally sponsored for MOC

Future directions in transitions of care

• Inter-professional communication at care

transitions

• Communication between consultative and

primary services

• Other transitions in addition to shift-to-shift

– Team to team (e.g. ED to inpatient), floor to MICU,

inpatient to outpatient

Learn more about I-PASS by watching the

24 minute “Core Content Video”

• www.hospitalmedicine.org/ipass (When you go to

this link, it says "access denied." Ignore that. Go up

to the right top corner and click "log on."

• username: BMC_IPASS

• password: Ipass123

• Under "Front-Line Provider Training Materials” �

IPASS Core Content Video Module.

Thank you for your support of this Quality

Improvement and Educational initiative that we

believe will have a positive impact on patient safety.

Please let us know if you have any comments or

feedback now and throughout the year.

Core I-PASS Implementation Team for Internal Medicine:

Karin Sloan

David Yuh, hospitalist/Quality Leader inpatient GIM

Faisal Rahman, Chief Resident

Katy Thompson, Chief Resident

Jordan Yoder, PGY3

Aravind Menon, PGY2

Craig Noronha, APD, Epic clinical lead for handoff tool